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探索指南在导致药物错误中的作用:对国家患者安全事件数据的描述性分析
Matthew D Jones1, Shaojun Liu2, Freyja Powell3
1Department of Life Sciences, University of Bath, Bath, BA2 7AY, UK. M.D.Jones@bath.ac.uk.
Drug safety
|February 2, 2024
概括
难以访问和使用临床指南导致成千上万的药物错误,影响患者的安全. 这些与指南相关的错误在处方和管理过程中经常发生,突出了改善医疗保健的关键领域.
科学领域:
- 医疗保健的质量和安全
- 药物管理 药物管理
- 临床实践指南 临床实践指南
背景情况:
- 临床指南旨在改善患者护理,但可能无意中导致药物错误.
- 缺乏对指南相关药物错误的类型和背景的全面了解.
研究的目的:
- 识别和分类与全国报告的临床指南相关的药物错误.
- 描述常见的错误类型,药物使用阶段,具体指导方针,涉及的药物,专业和临床环境.
主要方法:
- 对来自英格兰和威尔士的28,217起事件报告 (2016-2021) 的回顾性分析.
- 开发一个层次任务分析 (HTA) 来定义预期的指南使用.
- 编码了5708份关于HTA偏差的报告,重点是指导方针可访问性和信息利用.
主要成果:
- 在整个数据集中估计有超过3200个与指南相关的差异,其中642个在编码样本中确定.
- 常见的错误包括难以找到指南 (300份报告) 和使用指南信息 (176份报告) 的困难.
- 错误最常见的是当地制造的指导方针,并且发生在处方 (277 份报告) 和药物管理 (241 份报告) 期间.
结论:
- 在获取和解释临床指南方面的挑战导致了许多药物错误,包括处方和管理事件.
- 这些与指南相关的错误有助于严重伤害患者,强调需要改进指南设计和实施策略.
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